Agustín Sangines García

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Ashoka Fellow

Mexico

Fellow Since 1988

CATWLAC

This description of Agustín Sangines García's work was prepared when Agustín Sangines García was elected to the Ashoka Fellowship in 1988.

Introduction

Agustin Sangines is a doctor working closely with the Diocese of Tehuantepec in one of the most remote southern regions of the state of Oaxaca. His main concern is to make preventative low-cost medicine available to everybody. To achieve this he is setting up a regional health scheme that aims to end malnutrition-related disease and sicknesses owing to bad housing conditions, lack of sanitation, overwork, unhygienic conditions and lack of vaccinations.

The New Idea

Drawing on many years of experience working in rural and Indian regions of Mexico, Agustin has set up a regional health system which involves practical, action oriented training together with an innovative system for classifying diseases.
Agustin maintains that rather than creating new externally inspired organizations dealing with preventative medicine, existing grass roots organizations should be integrated into the network. From these organizations health promoters are recruited and trained sometimes in their own communities and sometimes in neighboring villages. He draws heavily upon traditional organizational structure both in terms of local groups he involves with regard to the customs of the region. Training sessions follow the tradition of fiestas and communal hospitality with different villages playing host to health promoters during weekend courses and these courses being open to whole host community not just the promoters from the next village.
Agustin maintains that it is impossible to separate health from social justice and sickness from injustice. They are interrelated in a cycle of poverty and disease, misery and sickness. Any approach to medicine must therefore consider the wider social context and not just the isolated individual and his or her particular illness. To this end, Agustin has devised a series of epidemiological sheets which register an individual's sickness and its apparent and essential causes.
As well as reducing child mortality and creating greater awareness of the needs for hygiene, safe and sanitary living conditions and better nutrition Agustin is setting up local dispensaries staffed by volunteers which will offer cheap, often herbal, remedies for common ailments. Agustin also expects to reduce risks involved in pregnancy and childbirth and the number of hospitalizations.
He is at present working in 17 zones in the region of the Isthmus of Tehuantepec with 50 health groups well established and another 50 in formation. Within a few years Agustin will start work on a national training program. He is convinced that his approach of "the medicine of liberation" is the only appropriate one for countries such as Mexico which still suffer centuries of oppression and social injustice particularly in the more remote rural areas.

The Problem

In rural areas of Mexico child malnutrition is almost 70% while in peripheral urban areas is reaches 40%. Moreover, diseases caused by ignorance and poor living conditions are prevalent: intestinal parasitosis, bacterial dysentery, respiratory and skin infections, alcoholism and drug addiction. In certain regions of Mexico, according to Agustin, intestinal parasitosis accounts for almost 100% of causes of mortality. And epidemics of tuberculosis, skin infections, and illnesses deriving from overwork are common.

Although the government provides health services through the Ministry of Health, this is not enough. These are divided into three levels: the first level is composed of the rural health centers staffed by a doctor who stays on average for one year only and is sometimes helped by a nurse. The second level consists of the urban health centers: the general hospital with a small number of beds for minor surgery cases. And the third level is the regional hospital with certain medical specializations. These services are supplemented by the health service for government employees and some private medical practices.

Suffice it to say that almost 30% of the rural population don't have access to the first level of health care. And almost twice that number don't have access to the regional clinics.

The problem is self evident. Extremely high epidemiological rates caused in the main by malnutrition and poverty, complete with an extremely deficient coverage of official health centers which are moreover dedicated to resolving rather than preventing sickness.

The Strategy

Agustin has a strategy for everything: from opening up new regions of the state where no health services have ever been offered to diagnosing disease and training health promoters both to prevent sickness and to train others.

When he wants to start work in a new region he begins making a diagnostic study. He identifies organizations that already exist in the region – maybe they're related to the school – a parents association, for example, or perhaps it's a credit union formed by the farmers. Once he's identified these organizations he then sets out to determine which organizations should be the ones to work with. He has a whole system for classifying, on the basis of interviews with people in the region, which organizations are 'democratic' and which are 'authoritarian'.

He then invites people from these organizations to participate as health promoters in the region. Agustin's philosophy is to “learn by doing.” So, once recruited, the health promoters start work after the very first training session. The health promoter forms his own health group which meets once a week to study what the promoter has seen in his training session. And the promoters themselves are trained once or twice a month for a total of four years.

One of their first actions is to set up a local dispensary. Although the people in the community are asked to donate one or two thousand pesos each (under a dollar) anybody who needs health advice can come to the dispensary. It is one of the basic philosophies of this system to attend the sick whether or not they can or will pay for the service.

The courses themselves follow Agustin's innovative system for classifying disease and enable both the promoter and patient to understand the root causes of the illness and aim to prevent rather than cure it. They are based on what Agustin calls the four pillars of the medicine of liberation: prevention, cure, conscientiousness, and organization.

The training itself is divided into three stages: initiation, consolidation, and projection. During the initial stages of training the promoters learn to use the epidemiological sheets which follow Agustin's classifications of disease. These are: sicknesses caused by lack of adequate nutrition, sicknesses caused by the lack of sanitation, sickness caused by lack of suitable housing and clothing, sicknesses caused by lack of washing, sicknesses caused by overwork, sicknesses caused by accidents, sicknesses caused by corruption in the health services, regional sicknesses, and sicknesses caused by a deformed education.

Each of these kinds of sickness are discussed and reflected upon and specific concrete actions to prevent them are proposed. For example, in sicknesses owing to lack of adequate sanitation, the promoters are trained in the construction of latrines, how to make water safe to drink, how to make compost from organic matter, etc. At the same time their own knowledge of herbal and traditional medicine is expanded upon and reinforced by suggesting specific therapeutic remedies for, to give an example, intestinal parasites.

Once the health promoters have completed the initial stage of the training process they go on the second stage of consolidation. Here they consider the broader implications of the classifications of diseases they have seen, and they begin to construct what Agustin calls the Social Tree of Health and Sickness.

At this stage also they begin to help out at clinics to gain experience in diagnosing sicknesses and in turn giving clinical advice in their own communities.

Finally once the promoters have reached the stage of being able to prevent, cure, inform, and organize, they become advanced health promoters and begin to go beyond their own specific communities to other villages in the region and to participate in national events and courses.

The Person

Born in Mexico City, Agustin was trained as a doctor at the National University of Mexico (UNAM) and took a specialization in Social Medicine at the Metropolitan University. A deeply committed Christian Agustin felt that it was through his skills as a doctor that he could best serve his fellow men. Immediately after qualifying as a doctor, Agustin left for Chiapas to work with the Jesuit Mission in Bachajon attending the small clinic and giving health courses in the Indian communities. It was here that Agustin first came to question the operating modes and classificatory systems of western medicine. And he became increasingly interested in understanding the points of contact between modern medical science and traditional indigenous world views on health and sickness.

After several years work in Chiapas, Agustin returned to Mexico City to take the master's specialization in social medicine, writing his thesis specifically on his experience in Chiapas. Now he turned his attention to peripheral areas of Mexico City, taking time off from his studies to prepare and train health promoters, in the Netzahualcoyotl area.

He stayed on at the University, this time commissioned to work as coordinator of doctors completing their service year in the state of Veracruz. There he carried out actions emphasizing the importance of the social nature of disease, and promoting the installation of potable drinking water, ecological latrines, garbage collection, etc. As a direct result of his seven years stay in Jalapa, child malnutrition decreased dramatically.

Finally two years ago, Agustin moved to Oaxaca at the request of the Bishop of Tehuantepec, to take charge of the health services offered by the diocese. It has been here that his experience and ideals have crystallized to give shape to the regional health service, that if things go right will in the next few years become a national one.